Radiation injury to the heart

Impaired vascular function in asymptomatic young adult survivors of Hodgkin Lymphoma following mediastinal radiation

BACKGROUND

Mediastinal radiation can accelerate atherosclerosis in Hodgkin lymphoma survivors (HLS), and early detection is optimal. Peripheral arterial tonometry (PAT), a non-invasive measure of endothelial function, is a surrogate marker of sub-clinical atherosclerosis. The objective of our study was to evaluate endothelial function in HLS and controls using PAT and to determine the influence of mediastinal radiation.

PROCEDURE

Cross-sectional evaluation was performed on 26 HLS aged 12-30 years who were a minimum of 2 years from therapy, and their healthy age and gender matched controls. Evaluation included assessment for cardiovascular risk factors and completion of the Habitual Activity Estimation Score (HAES) questionnaire to assess activity level. Endothelial Function was measured using PAT hyperemia ratios (PAT-HR).

RESULTS

HLS and controls were similar for baseline variables (mean age 23.3 +/- 5 yrs vs. 23.4 +/- 4.8 yrs, p = 0.92). HLS were on average 6.7 +/- 4.6 yrs post treatment. No differences in endothelial function or cardiovascular risk factors were observed between HLS and controls. However, impaired endothelial function, as evidenced by lower PAT-HR (1.67 +/- 0.39 vs. 2.03 +/- 0.37, p < 0.01) was seen in HLS (n = 13) who received mediastinal radiation (mean radiation dose 2,600 +/- 840 cGy) compared to controls.

CONCLUSIONS

Impaired endothelial function was preferentially observed in HLS who received mediastinal radiation, while no difference was observed between the HLS and control groups overall. This finding, assessed using a non invasive test of endothelial function, confirms that mediastinal radiation is an additional cardiovascular risk factor in this young cohort of patients. Further studies of endothelial function in this patient population are warranted.

Craniospinal radiotherapy in children: Electron- or photon-based technique of spinal irradiation

BACKGROUND

The prone position and electron-based technique for craniospinal irradiation (CSI) have been standard in our department for many years. But this immobilization is difficult for the anaesthesiologist to gain airway access. The increasing number of children treated under anaesthesia led us to reconsider our technique.

AIM

The purpose of this study is to report our new photon-based technique for CSI which could be applied in both the supine and the prone position and to compare this technique with our electron-based technique.

MATERIALS AND METHODS

Between November 2007 and May 2008, 11 children with brain tumours were treated in the prone position with CSI. For 9 patients two treatment plans were created: the first one using photons and the second one using electron beams for spinal irradiation. We prepared seven 3D-conformal photon plans and four forward planned segmented field plans. We compared 20 treatment plans in terms of target dose homogeneity and sparing of organs at risk.

RESULTS

In segmented field plans better dose homogeneity in the thecal sac volume was achieved than in electron-based plans. Regarding doses in organs at risk, in photon-based plans we obtained a lower dose in the thyroid but a higher one in the heart and liver.

CONCLUSIONS

Our technique can be applied in both the supine and prone position and it seems to be more feasible and precise than the electron technique. However, more homogeneous target coverage and higher precision of dose delivery for photons are obtained at the cost of slightly higher doses to the heart and liver.

The utility of non-axial treatment beam orientations for lower lobe lung cancers

Traditional treatment beams for non‐small–cell lung cancer are limited to the axial plane. For many tumor geometries, non‐axial orientations appear to reduce the dose to normal tissues (e.g. heart, liver). We hypothesize that non‐axial beams provide a significant reduction in incidental irradiation of the heart and liver, while maintaining adequate target coverage. CT scans of twenty‐four patients with lower lobe lung cancers were studied. For each patient, an opposed oblique axial beam pair and a competing non‐axial opposed oblique pair were generated, both off‐cord. The competing plans delivered comparable doses/margins to the GTV. DVHs and integral doses were computed for all structures of interest for the two competing plans. The integral dose was compared for axial and non‐axial beams for each contoured organ using a paired t‐test. Dose to the heart was significantly lower for the non‐axial plans (p=.0001). For 20/24 patients, the integral heart dose was reduced by using non‐axial beams. In those patients with tumors located in the inferior right lower lobe, a lower dose to the liver was achieved when non‐axial beams were used. There were no meaningful differences in dose to the GTV, lungs, or skin between axial and non‐axial beams. Non‐axial beams can reduce the dose to the heart and liver in patients with lower lobe lung cancers. Non‐axial beams may be clinically beneficial in these patients and should be considered as an option during planning.

PACS number: 87.55.de

A hanging mass in the ascending aorta diagnosed by transthoracic echocardiography in a totally asymptomatic subject

Aortic mural thrombosis is generally associated with several diseases, including coagulopathies, aortic dissection or trauma, tumors, and complicated atherosclerotic plaques. The development of a friable mobile thrombus, especially in the ascending aorta or proximal aortic arch, is a rare event with potentially ominous consequences because of a life-threatening risk of stroke and peripheral embolization. The treatment of choice of this condition is still controversial. We report a case of an absolutely asymptomatic 57-year-old patient with a mobile, pedunculated mass attached to the posterior wall of an otherwise normal ascending aorta. The aortic mass, identified by transthoracic echocardiography, was surgically removed and demonstrated to be a thrombus, and the aortic wall specimen was microscopically normal.

The potential cardioprotective effects of hydrogen in irradiated mice

Most ionizing radiation-induced damage is caused by hydroxyl radicals, and the selective reduction of hydroxyl by hydrogen in vitro has been demonstrated previously. Irradiation of the heart can cause chronic cardiac disease. This study was designed to test the hypothesis that hydrogen-rich water (pure water saturated with molecular hydrogen), which is easy to use, induces cardioprotection against ionizing irradiation injury in mice. In this paper, we demonstrate that hydrogen can protect myocardium degeneration from radiation-induced injury, decrease myocardium malondialdehyde (MDA), 8-hydroxydeoxyguanosine (8-OHdG) levels, and increase myocardium endogenous antioxidants in vivo. We suggest that hydrogen has a cardioprotective effect against radiation induced injury.

Spectrum of pericardial disease: part II

Pericardial disease is a common disorder seen in varying clinical settings, and may be the first manifestation of an underlying systemic disease. In part I, we focused on the current knowledge and management of the more common pericardial diseases: acute pericarditis, pericardial effusion, cardiac tamponade, chronic pericarditis and relapsing pericarditis. In part II, we will focus on the knowledge and management of pericardial involvement in chylous pericardial effusion cholesterol pericarditis, radiation pericarditis, pericardial involvement in systemic inflammatory diseases, autoreactive pericarditis, pericarditis in renal failure, pericardial constriction and effusive constrictive pericarditis.

Effects of adenovirus-mediated delivery of the human hepatocyte growth factor gene in experimental radiation-induced heart disease

PURPOSE

Irradiation to the heart may lead to late cardiovascular complications. The purpose of this study was to investigate whether adenovirus-mediated delivery of the human hepatocyte growth factor gene could reduce post-irradiation damage of the rat heart and improve heart function.

METHODS AND MATERIALS

Twenty rats received single-dose irradiation of 20 Gy gamma ray locally to the heart and were randomized into two groups. Two weeks after irradiation, these two groups of rats received Ad-HGF or mock adenovirus vector intramyocardial injection, respectively. Another 10 rats served as sham-irradiated controls. At post-irradiation Day 120, myocardial perfusion was tested by myocardial contrast echocardiography with contrast agent injected intravenously. At post-irradiation Day 180, cardiac function was assessed using the Langendorff technique with an isolated working heart model, after which heart samples were collected for histological evaluation.

RESULTS

Myocardial blood flow was significantly improved in HGF-treated animals as measured by myocardial contrast echocardiography at post-irradiation Day 120 . At post-irradiation Day 180, cardiac function was significantly improved in the HGF group compared with mock vector group, as measured by left ventricular peak systolic pressure (58.80 +/- 9.01 vs. 41.94 +/- 6.65 mm Hg, p < 0.05), the maximum dP/dt (5634 +/- 1303 vs. 1667 +/- 304 mm Hg/s, p < 0.01), and the minimum dP/dt (3477 +/- 1084 vs. 1566 +/- 499 mm Hg/s, p < 0.05). Picrosirius red staining analysis also revealed a significant reduction of fibrosis in the HGF group.

CONCLUSION

Based on the study findings, hepatocyte growth factor gene transfer can attenuate radiation-induced cardiac injury and can preserve cardiac function.

Hepatocyte growth factor protects endothelial cells against gamma ray irradiation-induced damage

AIM

To investigate the effect of HGF on proliferation, apoptosis and migratory ability of human vascular endothelial cells against gamma ray irradiation.

METHODS

ECV304 cells derived from adult human umbilical vein endothelial cells (HUVEC) were irradiated with a single gamma ray dose of 20 Gy. Immunocytochemistry and Western blot analysis were used to detect c-Met protein expression and HGF/c-Met signal pathway. In the HGF-treated groups, ECV304 cells were incubated with HGF (20 or 40 ng/mL) 3 h prior to irradiation. At 48 h post-irradiation, the proliferation of ECV304 cells was measured by MTT assay, the apoptosis was assessed by flow cytometry, and the migratory ability of ECV304 cells was measured by transwell chamber assay.

RESULTS

c-Met protein is expressed in ECV304 cells and can be activated by HGF. Gamma ray irradiation inhibits proliferation and migration of ECV304 cells in a dose-dependent manner. HGF significantly promoted the proliferation of ECV304 cells, and flow cytometry revealed that HGF can inhibit apoptosis of ECV304 cells. Transwell chamber assay also showed that HGF increases migration activity of endothelial cells.

CONCLUSION

HGF may afford protection to vascular endothelial cells against gamma ray irradiation-induced damage.

Can cutaneous telangiectasiae as late normal-tissue injury predict cardiovascular disease in women receiving radiotherapy for breast cancer?

Background:

Overall, ∼5% of patients show late normal-tissue damage after radiotherapy with a smaller number having a risk of radiation-induced heart disease. Although the data are conflicting, large studies have shown increased risks of cardiovascular disease (CVD) for irradiated patients compared with non-irradiated ones, or for those treated to the left breast or chest wall compared with those treated to the right. Cutaneous telangiectasiae as late normal-tissue injury have so far only been regarded as a cosmetic burden.

Methods:

The relationship between late normal-tissue radiation injury phenotypes in 149 irradiated breast cancer patients and the presence of cardiovascular disease were examined.

Results:

A statistically significant association between the presence of skin telangiectasiae and the long-term risk of CVD was shown in these patients (P=0.017; Fisher's exact test).

Interpretation:

This association may represent initial evidence that telangiectasiae can be used as a marker of future radiation-induced cardiac complications. It could also suggest a common biological pathway for the development of both telangiectasiae and CVD on the basis of a genetically predisposed endothelium. To our knowledge this is the first reported study looking at this association.

Radiotherapy and adjuvant trastuzumab in operable breast cancer: tolerability and adverse event data from the NCCTG Phase III Trial N9831

PURPOSE

To assess whether trastuzumab (H) with radiotherapy (RT) increases adverse events (AEs) after breast-conserving surgery or mastectomy.

PATIENTS AND METHODS

Patients with early-stage resected human epidermal growth factor receptor 2 (HER-2) -positive breast cancer (BC) were randomly assigned to doxorubicin (A) and cyclophosphamide (C), followed by weekly paclitaxel (T; AC-T-H or AC-TH-H). RT criteria (with or without nodal RT) were postlumpectomy breast or (optional) postmastectomy chest wall. RT of internal mammary nodes was prohibited. RT commenced within 5 weeks after T, concurrently with H. Analysis included 1,503 irradiated patients for RT-associated AEs across treatment arms. Rates of cardiac events (CEs) with and without RT were compared within arms.

RESULTS

No significant differences among arms were found in incidence of acute skin reaction, pneumonitis, dyspnea, cough, dysphagia, or neutropenia. A significant difference occurred in incidence of leukopenia, with higher rates for AC-T-H versus AC-T (odds ratio = 1.89; 95% CI, 1.25 to 2.88). At a median follow-up of 3.7 years (range, 0 to 6.5 years), RT with H did not increase relative frequency of CEs regardless of treatment side. The cumulative incidence of CEs with AC-T-H was 2.7% with or without RT. With AC-TH-H, the cumulative incidence was 1.7% v 5.9% with or without RT, respectively.

CONCLUSION

Concurrent adjuvant RT and H for early-stage BC was not associated with increased acute AEs. Further follow-up is required to assess late AEs.

Cardiovascular effects of physiological and standard sex steroid replacement regimens in premature ovarian failure

Current hormone replacement therapy may not optimize cardiovascular health in women with premature ovarian failure. We compared the effects of physiological and standard sex steroid replacement regimens on cardiovascular health in these women. In an open-label, randomized, controlled crossover trial, 34 women with premature ovarian failure were randomly assigned to 4-week cycles of physiological (transdermal estradiol and vaginal progesterone) and standard (oral ethinylestradiol and norethisterone) therapy for 12 months. Cardiovascular health was assessed by 24-hour ambulatory blood pressure, arterial stiffness, and renal and humoral factors. Eighteen women (19 to 39 years of age) completed the 28-month protocol. Both regimens caused similar suppression of luteinizing hormone and follicle-stimulating hormone and provided symptom relief. In comparison with the standard regimen, physiological sex steroid replacement caused lower mean 24-hour systolic and diastolic blood pressures throughout the 12-month treatment period (ANOVA; P<or=0.0001 for both): systolic blood pressure was 7.3 mm Hg (95% CI: 2.5 to 12.0 mm Hg) and diastolic was 7.4 mm Hg (95% CI: 3.9 to 11.0 mm Hg) lower at 12 months. Although there were no differences in arterial stiffness, physiological sex steroid replacement reduced plasma angiotensin II (ANOVA; P=0.007) and serum creatinine (ANOVA; P=0.015) concentrations without altering plasma aldosterone concentrations. In comparison with a standard regimen, physiological sex steroid replacement in women with premature ovarian failure results in lower blood pressure, better renal function, and less activation of the renin-angiotensin system. These findings have major implications for the future cardiovascular health of young women who require long-term sex steroid replacement therapy.

The diagnosis and management of cardiovascular disease in cancer patients

Cardiovascular disease is commonly found in cancer patients. The co-existence of heart disease and cancer in a patient often complicates treatment, because therapy for one disease may negatively affect the outcome of the other disease. In addition, guidelines for the treatment of cardiovascular disease are often based on studies, which exclude patients who have cancer. In this review we will discuss the diagnosis and management of cardiovascular disease in cancer patients. We will focus on cancer-related causes of cardiovascular disease and special treatment options for cardiovascular disease in cancer patients. The cardiac complications of cancer therapy will be discussed according to common syndromes: left ventricular dysfunction, myocardial ischemia, blood pressure changes, thromboembolism, bradyarrhythmias, and prolonged QT interval.

Monitoring for cardiovascular disease in survivors of childhood cancer: report from the Cardiovascular Disease Task Force of the Children's Oncology Group

Curative therapy for childhood cancer has improved significantly in the last 2 decades such that, at present, approximately 80% of all children with cancer are likely to survive > or = 5 years after diagnosis. Prevention, early diagnosis, and treatment of long-term sequelae of therapy have become increasingly more significant as survival rates continue to improve. Cardiovascular disease is a well-recognized cause of increased late morbidity and mortality among survivors of childhood cancer. The Children's Oncology Group Late Effects Committee and Nursing Discipline and Patient Advocacy Committee have recently developed guidelines for follow-up of long-term survivors of pediatric cancer. A multidisciplinary task force critically reviewed the existing literature to evaluate the evidence for the cardiovascular screening recommended by the Children's Oncology Group guidelines. In this review we outline the clinical manifestations of late cardiovascular toxicities, suggest modalities and frequency of monitoring, and address some of the controversial and unresolved issues regarding cardiovascular disease in childhood cancer survivors.

Thoracic radiotherapy in patients with lymphoma and restenosis after coronary stent placement

OBJECTIVES

The aim of this study was to assess the incidence of restenosis after coronary stenting in patients with lymphoma treated with thoracic radiation.

BACKGROUND

Patients with Hodgkin lymphoma treated with thoracic radiation have an increased incidence of coronary artery disease (CAD). The incidence of restenosis after percutaneous coronary interventions is completely unknown.

METHODS

This study included 12,626 consecutive patients with CAD treated with coronary stenting during a 10-year period. Within this cohort, three subgroups of patients were assessed: patients with lymphoma and previous thoracic radiation (15 patients), patients with lymphoma without thoracic radiation (7 patients) and patients without lymphoma or previous thoracic radiation (control group; 12,604 patients). Coronary stenting was performed after a median [25th; 75th percentiles] of 8 years [4; 17] after thoracic radiation. The primary end point of the study was restenosis at 6-month coronary angiography.

RESULTS

Six-month coronary angiography was performed in 14 patients (93%) in the group with lymphoma and radiation, 6 patients (86%) in the group with lymphoma without radiation and 10,032 patients (80%) in the control group (P = 0.38). Angiographic restenosis was found in 12 patients (85.7%) in the group with lymphoma and radiation, 1 patient (16.7%) in the group with lymphoma without radiation and 2,555 patients (25.5%) in the control group (P < 0.001). Multiple logistic regression identified thoracic radiation as an independent predictor of coronary restenosis (odds ratio 21.7, 95% confidence interval, 4.7-100.9, P < 0.001).

CONCLUSIONS

Patients with lymphoma treated with thoracic radiation have an increased risk of restenosis after coronary artery stenting.

The risk of death from heart disease in patients with nonsmall cell lung cancer who receive postoperative radiotherapy: analysis of the Surveillance, Epidemiology, and End Results database

BACKGROUND

This study was designed to investigate whether the mortality from heart disease, a manifestation of intercurrent disease after postoperative radiotherapy (PORT), has decreased over time for patients with nonsmall cell lung cancer (NSCLC).

METHODS

The 17-registry 1973 to 2003 dataset from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program was used to create a cohort of patients with NSCLC who had evidence of ipsilateral lymph node involvement diagnosed from 1983 to 1993 and who underwent pnuemonectomy/lobectomy (n = 6148 patients). Heart disease mortality was the primary endpoint: Deaths from other causes were censored, and surviving patients were censored at 10 years. The independent variable was PORT use, and adjustment variables included age at diagnosis, sex, race, year of diagnosis, laterality, location, histology, and the operation performed.

RESULTS

Multivariate analysis revealed that PORT use was associated with an increase in heart disease mortality (hazards ratio [HR], 1.30; 95% confidence interval [95% CI], 1.04-1.61; P = .0193) along with older age, male sex, African-American race, and earlier year of diagnosis. The association was confirmed in the cohort that was diagnosed from 1983 to 1988 (HR, 1.49; 95% CI, 1.11-2.01 [P = .0090]) but not for the cohort that was diagnosed from 1989 to 1993 (HR, 1.08; 95% CI, 0.79-1.48 [P = .6394]).

CONCLUSIONS

The results from this study demonstrated that the risk of heart disease mortality associated with PORT has declined in more recent years. This may be secondary to improvements in the treatment planning and delivery of thoracic radiotherapy. Properly designed, prospective, adjuvant trials will be needed to verify these findings.

Intensity-Modulated Radiotherapy for Craniospinal Irradiation: Target Volume Considerations, Dose Constraints, and Competing Risks

PURPOSE

To report the results of an analysis of dose received to tissues and organs outside the target volume, in the setting of spinal axis irradiation for the treatment of medulloblastoma, using three treatment techniques.

METHODS AND MATERIALS

Treatment plans (total dose, 23.4 Gy) for a standard two-dimensional (2D) technique, a three-dimensional (3D) technique using a 3D imaging-based target volume, and an intensity-modulated radiotherapy (IMRT) technique, were compared for 3 patients in terms of dose-volume statistics for target coverage, as well as organ at risk (OAR) and overall tissue sparing.

RESULTS

Planning target volume coverage and dose homogeneity was superior for the IMRT plans for V(95%) (IMRT, 100%; 3D, 96%; 2D, 98%) and V(107%) (IMRT, 3%; 3D, 38%; 2D, 37%). In terms of OAR sparing, the IMRT plan was better for all organs and whole-body contour when comparing V(10Gy), V(15Gy), and V(20Gy). The 3D plan was superior for V(5Gy) and below. For the heart and liver in particular, the IMRT plans provided considerable sparing in terms of V(10Gy) and above. In terms of the integral dose, the IMRT plans were superior for liver (IMRT, 21.9 J; 3D, 28.6 J; 2D, 38.6 J) and heart (IMRT, 9 J; 3D, 14.1J; 2D, 19.4 J), the 3D plan for the body contour (IMRT, 349 J; 3D, 337 J; 2D, 555 J).

CONCLUSIONS

Intensity-modulated radiotherapy is a valid treatment option for spinal axis irradiation. We have shown that IMRT results in sparing of organs at risk without a significant increase in integral dose.

Cardiovascular effects of breast cancer radiotherapy

Cardiac toxicity has been implicated as the primary reason for excess non-breast cancer mortality in early breast cancer radiotherapy studies. Refinements in radiotherapy techniques have allowed for a considerable reduction of this risk in the majority of breast cancer patients. Recent large population-based studies confirmed an increase of cardiovascular death risk in patients irradiated for cancer of the left breast and in individuals exposed to relatively low (hitherto believed to be of no cardiovascular disease risk) doses of radiation, such as atomic bomb survivors or patients treated for various benign conditions. The issue of potential radiation-related cardiac damage may also be assuming a new significance due to the widespread use of other cardiotoxic agents, such as anthracyclines, paclitaxel and trastuzumab. The aim of this review is to summarize and critically analyze the available evidence on the impact of ionizing radiation on the cardiovascular system, with special attention to recent data demonstrating previously unrecognized adverse effects. This review discusses the pathology of radiation-related cardiovascular disease, its clinical presentation, risk factors and methods of assessment, as well as technical developments minimizing cardiac exposure. Epidemiological data are presented on the incidence of radiation-induced heart disease and cardiovascular mortality in various populations of patients irradiated for breast cancer and in individuals exposed to low radiation doses. Additionally, non-cardiac radiation-related vascular morbidity and mortality in breast cancer patients are addressed.

Risk factors for enlargement of cardiac silhouette on chest radiography after radiotherapy for esophageal cancer

PURPOSE

To evaluate the incidence and risk factors of enlargement of cardiac silhouette on chest radiographs after radiotherapy for esophageal cancer.

MATERIALS AND METHODS

We analyzed 67 patients with esophageal cancer who received external beam radiation therapy with a total dose of >or=50 Gy and were followed for >or=6 months. Sixteen patients received radiation alone, and the remaining 51 received chemoradiotherapy. The difference between the cardiothoracic ratio (CTR) on the pretreatment chest radiograph and that on the posttreatment radiograph with maximum cardiac silhouette for each patient was used for the analysis.

RESULTS

The average maximum increase in CTR for the entire group was 4.5%, which was statistically significant. Only the area of the cardiac silhouette in the initial radiation field was a significant risk factor for enlargement of the cardiac silhouette. Pericardial effusions were observed in all patients who underwent computed tomography with severe enlargement of the cardiac silhouette.

CONCLUSION

The CTR value significantly increased after radiotherapy for esophageal cancer. Radiation-induced pericardial effusion may be the main cause of enlargement of the cardiac silhouette. The irradiated cardiac area was the only significant risk factor for enlargement of the cardiac silhouette; the use of chemotherapy was not.

Cardiovascular calcifications after radiation therapy for Hodgkin lymphoma: computed tomography detection and clinical correlation

OBJECTIVE

To study cardiovascular calcifications, detected by computed tomography, in patients following mediastinal radiation for Hodgkin lymphoma, and correlate them with clinical findings.

MATERIALS AND METHODS

Fifteen patients, <or=55 years, with computed tomography detected cardiovascular calcifications after mediastinal radiotherapy for Hodgkin lymphoma were identified during a 10-year period. Calcifications were evaluated for site and extent and were correlated with clinical data including symptoms and signs of heart disease, angiographic and surgical findings.

RESULTS

Accelerated calcifications were detected in the coronary arteries (n=11), in the aorta (n=11), and in the aortic valve and the mitral apparatus (n=8). Calcifications were more extensive when radiation was given at a young age. Clinical evidence of cardiovascular disease included coronary events in three patients, valvular dysfunction in two, pericarditis in two and complete atrioventricular block in one. Seven patients had no cardiac symptoms.

CONCLUSION

Early cardiovascular calcifications can be radiation associated. Such calcifications may represent radiation-induced atherosclerosis and can be detected by computed tomography even in asymptomatic patients. The implication of our findings is that spiral computed tomography may serve as a non-invasive modality to detect accelerated cardiovascular calcifications in high-risk asymptomatic patients who survived Hodgkin lymphoma.

Late toxicity in complete response cases after definitive chemoradiotherapy for esophageal squamous cell carcinoma

BACKGROUND

We retrospectively investigated long-term toxicity after concurrent chemoradiotherapy (CRT) for patients with esophageal squamous cell carcinoma (ESCC).

METHODS

Concurrent chemoradiotherapy was performed in 110 patients with T1 to T4 disease containing M1 lymph node (LYM) disease. Chemotherapy consisted of protracted infusion of 5-fluorouracil 400 mg/m(2) per 24 h on days 1 to 5 and 8 to 12, combined with 2-h infusion of cisplatin 40 mg/m(2) on days 1 and 8. Radiation treatment of the mediastinum at a dose of 30 Gy in 15 fractions was administered concomitantly with chemotherapy. A course schedule with a 3-week treatment and a 2-week break was applied twice, with a total radiation dose of 60 Gy. For the assessment of toxicity, the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer late radiation morbidity scoring schema was adopted.

RESULTS

A total of 81 patients were recruited in patients with stage I to IVA. Of 34 patients with complete response, 1 patient died as a result of acute myocardial infarction. Grade 2, 3, and 4 late toxicities occurred with the following incidences: pericarditis in 3 patients, 1 patient, and 2 patients, respectively; heart failure in 0, 0, and 3 patients; pleural effusion in 2, 3, and 0 patients; and radiation pneumonitis in 0, 0, and 1 patient, respectively.

CONCLUSIONS

Definitive chemoradiotherapy for ESCC is effective with substantial toxicities. Further investigation is warranted to minimize the normal tissue toxicities.

Folgeerkrankungen nach Chemotherapie

Today, about 60% of adult patients and 80% children diagnosed with cancer will survive 5 years after diagnosis. Approximately two thirds of cancer survivors will experience at least one late effect, and about one third severe or life threatening late effects. The aim of cancer treatment today is to cure the malignant disease but at the same time, to minimize the incidence of post-treatment complications. In the current overview we summarize, based on the most recent publications, typical late effects in cancer survivors.

Late non-neoplastic events in patients with aggressive non-Hodgkin's lymphoma in four randomized European Organisation for Research and Treatment of Cancer trials

BACKGROUND

A significant proportion of patients with aggressive non-Hodgkin's lymphoma (NHL) become long-term survivors. A European Organisation for Research and Treatment of Cancer database of patients with aggressive NHL, consistently treated with doxorubicin-based chemotherapy since 1980, afforded the possibility to explore late complications in this patient group.

PATIENTS AND METHODS

Of 951 randomized patients, complete data on late complications could be collected in 757 patients who were alive > or = 2 years after the start of therapy and were seen at yearly follow-ups (median follow-up, 9.4 years; range, 2.1-20.4 years). We computed cumulative incidences of late events in a competing risk model by Gray (death being the competing event) to avoid bias caused by the high percentage of NHL-related deaths. Risk factors were estimated in a Cox proportional-hazards model and also evaluated with the Gray test.

RESULTS

Late non-neoplastic events were found in 46% of the 757 patients. At 15 years, the cumulative incidences of cardiac disease and infertility were 20% and 29%, respectively. Renal insufficiency (11%), acquired hypertension (8%), and disabling neuropathy (13%) were also frequent. Salvage treatment was a risk factor in most cases. Smoking, age > 50 years during treatment, and preexistent hypertension were the main risk factors for cardiovascular disease. In-field radiation therapy (RT) was related to hypothyroidism, lung fibrosis, hypertension, gastrointestinal toxicity, and renal insufficiency but not to cardiovascular events. Autologous stem cell transplantation and cisplatin- and MOPP (mechlorethamine/vincristine/procarbazine/prednisone)-containing therapies were associated with infertility and renal insufficiency.

CONCLUSION

Altogether, almost half the patients with aggressive NHL experienced events addressed as late non-neoplastic complications. Salvage therapy, smoking, age > 50 years, and in-field RT are important risk factors.

Quantification and reduction of cardiac dose in radical radiotherapy for oesophageal cancer

Chemoradiation is increasingly used in the management of localized oesophageal cancer and has been shown in randomized controlled trials to improve overall survival. Although early toxicity of radiotherapy is well documented, this is not the case for late toxicity. As patients with oesophageal cancer have a high incidence of co-morbidities including cardiac problems, the aim of this paper was to quantify the extent of cardiac radiation and discuss the influence of beam arrangement to reduce this. Eight patients with localized oesophageal cancer treated with radical chemoradiation were selected. The mean cardiac dose and the volumes of heart receiving 30 Gy, 40 Gy and 45 Gy from the conventional two-phase technique were compared with those of single-phase 3-field and 4-field conformal beam arrangements. The 4-field arrangement reduced the mean cardiac dose by at least 3.3 Gy compared with the other two beam arrangements (p=0.01). The mean volume of heart receiving high doses between the three techniques widened as the dose increased in the range 30-45 Gy. There is no statistically significant difference in volumes receiving more than 30 Gy and 40 Gy. 65% of the cardiac volume received more than 45 Gy using a two-phase technique, compared with 57% using three fields and 26% using four fields (p<0.01). With a 4-field beam arrangement, therefore, there is a significant reduction in cardiac dose compared with the other two techniques. Cardiac toxicity and a 4-field beam arrangement should be considered when planning radical radiotherapy for localized oesophageal cancer.

Cardiac function after chemoradiation for esophageal cancer: comparison of heart dose-volume histogram parameters to multiple gated acquisition scan changes

In this paper we determine if preoperative chemoradiation for locally advanced esophageal cancer leads to changes in cardiac ejection fraction. This is a retrospective review of 20 patients treated at our institution for esophageal cancer between 2000 and 2002. Multiple gated acquisition cardiac scans were obtained before and after platinum-based chemoradiation (50.4 Gy). Dose-volume histograms for heart, left ventricle and left anterior descending artery were analyzed. Outcomes assessed included pre- and postchemoradiation ejection fraction ratio and percentage change in ejection fraction postchemoradiation. A statistically significant difference was found between median prechemoradiation ejection fraction (59%) and postchemoradiation ejection fraction (54%) (P = 0.01), but the magnitude of the difference was not clinically significant. Median percentage volume of heart receiving more than 20, 30 and 40 Gy were 61.5%, 58.5% and 53.5%, respectively. Our data showed a clinically insignificant decline in ejection fraction following chemoradiation for esophageal cancer. We did not observe statistically or clinically significant associations between radiation dose to heart, left ventricle or left anterior descending artery and postchemoradiation ejection fraction.

Imaging of the Patient with Non–Small Cell Lung Cancer

Lung cancer is the most common type of cancer and is the leading cause of cancer deaths in the United States for both men and women. Even though the 5-year survival rate of patients with lung cancer remains dismal at 14% for all cancer stages, treatments are improving and newer agents for lung cancer appear promising. Therefore, an accurate assessment of the extent of disease is critical to determine whether the patient is treated with surgical resection, radiation therapy, chemotherapy, or a combination of these modalities. Radiologic imaging plays an important role in the staging evaluation of the patient; however, radiologists need to be aware that there are also important differences in what each specialist needs from imaging to provide appropriate treatment. This article reviews the role of imaging in patients with non-small cell lung cancer, with an emphasis on the radiologic imaging findings relevant for each specialty.

Cardiac Morbidity of Adjuvant Radiotherapy for Breast Cancer

Purpose

Adjuvant breast irradiation has been associated with an increase in cardiac mortality, because left-sided breast radiation can produce cardiac damage. The purpose of this study was to determine whether modern adjuvant radiotherapy is associated with increased risk of cardiac morbidity.

Patients and Methods

Data from the Surveillance, Epidemiology, and End Results–Medicare database were used for women who were diagnosed with nonmetastatic breast cancer from 1986 to 1993, had known disease laterality, underwent breast surgery, and received adjuvant radiotherapy. The Cox proportional-hazards model was used to compare patients with left- versus right-sided breast cancer for the end points of hospitalization with the following discharge diagnoses (International Classification of Diseases, 9th Revision codes): ischemic heart disease (410-414, 36.0, and 36.1), valvular heart disease (394-397, 424, 35), congestive heart failure (428, 402.01, 402.11, 402.91, and 425), and conduction abnormalities (426, 427, 37.7-37.8, and 37.94-37.99).

Results

Eight thousand three hundred sixty-three patients had left-sided breast cancer, and 7,907 had right-sided breast cancer. Mean follow-up was 9.5 years (range, 0 to 15 years). There were no significant differences in patients with left- versus right-sided cancers for hospitalization for ischemic heart disease (9.9% v 9.7%), valvular heart disease (2.9% v 2.8%), conduction abnormalities (9.7% v 9.6%), or heart failure (9.7% v 9.7%). The adjusted hazard ratio for left- versus right-sided breast cancer was 1.05 (95% CI, 0.94 to 1.16) for ischemic heart disease, 1.07 (95% CI, 0.89 to 1.30) for valvular heart disease, 1.07 (95% CI, 0.96 to 1.19) for conduction abnormalities, and 1.05 (95% CI, 0.95 to 1.17) for heart failure.

Conclusion

With up to 15 years of follow-up there were no significant differences in cardiac morbidity after radiation for left- versus right-sided breast cancer.

The incidence and functional consequences of RT-associated cardiac perfusion defects

PURPOSE

Radiation therapy (RT) for left-sided breast cancer has been associated with cardiac dysfunction. We herein assess the temporal nature and volume dependence of RT-induced left ventricular perfusion defects and whether these perfusion defects are related to changes in cardiac wall motion or alterations in ejection fraction.

METHODS

From 1998 to 2001, 114 patients were enrolled onto an IRB-approved prospective clinical study to assess changes in regional and global cardiac function after RT for left-sided breast cancer. Patients were imaged 30 to 60 minutes after injection of technetium 99m sestamibi or tetrofosmin. Post-RT perfusion scans were compared with the pre-RT studies to assess for RT-induced perfusion defects as well as functional changes in wall motion and ejection fraction. Two-tailed Fisher's exact test and the Cochran-Armitage test for linear trends were used for statistical analysis.

RESULTS

The incidence of new perfusion defects 6, 12, 18, and 24 months after RT was 27%, 29%, 38%, and 42%, respectively. New defects occurred in approximately 10% to 20% and 50% to 60% of patients with less than 5%, and greater than 5%, of their left ventricle included within the RT fields, respectively (p = 0.33 to 0.00008). The rates of wall motion abnormalities in patients with and without perfusion defects were 12% to 40% versus 0% to 9%, respectively; p values were 0.007 to 0.16, depending on the post-RT interval.

CONCLUSIONS

Radiation therapy causes volume-dependent perfusion defects in approximately 40% of patients within 2 years of RT. These perfusion defects are associated with corresponding wall-motion abnormalities. Additional study is necessary to better define the long-term functional consequences of RT-induced perfusion defects.

Immediate Breast Reconstruction can Impact Postmastectomy Irradiation

OBJECTIVE

Immediate breast reconstruction is an attractive option for patients who undergo mastectomy. The purpose of this study was to qualitatively assess the effect of immediate reconstruction on the design of postmastectomy radiotherapy fields at our institution.

METHODS

We retrospectively reviewed the records of 152 patients treated at our institution with postmastectomy radiotherapy over a 1-year period. We identified 18 postmastectomy radiotherapy plans in the setting of prior reconstruction. By consensus, 2 board-certified radiation oncologists scored the 18 plans in terms of 4 outcomes: coverage of the chest wall breadth, coverage of the ipsilateral internal mammary chain (IMC) region, minimization of lung exposure, and avoidance of the heart.

RESULTS

Only 4 of the 18 plans resulted in optimal treatment of the chest wall breadth and IMC region while well avoiding the heart and lung. Of the remaining 14 plans, 12 compromised coverage of the chest wall breadth medially and/or laterally, and 9 provided no IMC coverage.

CONCLUSION

Immediate breast reconstruction may impose limitations on the treatment planning of postmastectomy radiotherapy, particularly in regard to providing broad coverage of the chest wall and IMC region while avoiding excess exposure of the heart and lung.

Cardiac complications of radiation therapy

AIMS

To present an overview of cardiac complications arising from radiation therapy.

MATERIALS AND METHODS

Medline the (February 2004) and Embase (1974 to February 2004) searches of the medical literature relating to the cardiac complications of radiotherapy were conducted.

RESULTS

Radiation damage may affect the pericardium, myocardium or coronary vasculature, and consists of fibrotic or small vessel damage. Cardiac complications are a particular problem with radiation treatments to the mediastinum and breast, especially when greater than 65% of the heart is irradiated. Most of the literature relates to the treatment of Hodgkin's disease, as patients with this disease tend to be young and live long enough to manifest late cardiac complications. Pericarditis, angina, myocardial infarction and arrhythmias are the most frequent causes of morbidity, with myocardial infarction being the most common fatal complication. The incidence of ischaemic heart disease does not increase rapidly until 10 years from treatment.

CONCLUSIONS

Much of the evidence relates to the use of outdated radiation therapy equipment and techniques. Today's patients almost certainly have a lower risk of cardiac complications. Cardiac complications are probably under-reported, as they occur long after cured patients have been discharged from follow-up.

Cardiovascular effects of radiation therapy: practical approach to radiation therapy-induced heart disease

Radiation induced heart diseases (RIHD) are increasingly recognized as more patients who received radiation therapy survive their diseases with improved management of various malignancies. Radiation affects every component of the heart, ranging from subclinical histopathologic changes to overt clinical disease. Pericardial involvement is the most common and includes asymptomatic pericardial effusion and constrictive pericarditis. The diseases involving the myocardium, valvular apparatus, and conduction system are often subclinical. When symptomatic, they are often the harbinger of more lethal, but treatable, radiation-induced coronary artery disease (CAD). Improvements in the modern radiation delivery systems have minimized irradiation of the heart. However, with increased and emerging indications for radiation therapy for various malignancies in the chest, as a part of bone marrow transplantations, and as the main agent of brachytherapy for advanced preexisting CAD, the incidence of RIHD is likely to increase. Appropriate management of RIHD, either overt or occult, must include understanding the natural history of RIHD, recognition of symptoms by careful history, and vigilant search for treatable causes of the RIHD or other diseases that might mimic RIHD. This article focuses on providing practical yet comprehensive clinical information for general internal medicine and cardiology practices.

Photodynamic therapy as salvage treatment for local failures after definitive chemoradiotherapy for esophageal cancer

BACKGROUND

Although definitive chemoradiotherapy for esophageal cancer shows a high response rate, persistent or recurrent locoregional disease remains a major problem. Salvage esophagectomy is the only curative intent treatment option; however, it carries higher morbidity and mortality rates than primary esophagectomy. Response to second-line chemotherapy is quite dismal.

METHODS

From December 2002 to November 2003, we applied salvage photodynamic therapy to 13 patients with local failures after completion of chemoradiotherapy, 4 patients had local recurrence after achieving a complete response, and 9 had a persistent tumor after chemoradiotherapy. The decision to treat was based on patients' refusal of salvage surgery or chemotherapy. After the intravenous administration of 2 mg/kg of Photofrin, photoradiation treatment with an excimer dye laser was performed for 48 hours and 72 hours after the injection. Written informed consent was obtained from all patients.

RESULTS

Eight patients (62%) achieved a complete response. After a median follow-up period of 12 months after photodynamic therapy, 6 patients were still free of disease, and the overall survival rate at 1 year was 68.4%. There were no treatment-related deaths.

CONCLUSIONS

Our results show that salvage photodynamic therapy could be a promising curative intent treatment option with low morbidity and mortality rates.

External Beam Radiation to Prevent Restenosis After Superficial Femoral Artery Balloon Angioplasty

Background— Femoropopliteal percutaneous transluminal angioplasty (PTA) remains limited by restenosis. Although vascular brachytherapy may be effective in reducing restenosis, external beam radiation would be more practical to administer after PTA.

Methods and Results— After femoropopliteal PTA without stent placement, 99 patients were randomly assigned to 0 Gy (placebo; n=24), 7 Gy (n=24), 10.5 Gy (n=26), or 14 Gy (n=25) of external beam radiation of the PTA site (with a 3-cm margin at both extremities) in 1 session 24 hours after PTA. The primary end point was minimum lumen diameter on quantitative angiography 1 year after PTA. One year after PTA, the mean minimum lumen diameter was 1.92, 1.64, 1.92, and 2.91 mm, respectively, for the 0-, 7-, 10.5-, and 14-Gy groups ( P =0.0072 for 0 versus 14 Gy). Mean luminal loss was 1.14, 1.27, 1.08, and 0.14 mm, respectively, for the 4 groups ( P =0.0072 for 0 versus 14 Gy). Restenosis >50% was present in 50%, 65%, 48%, and 25% of patients, respectively, for the 0-, 7-, 10.5-, and 14-Gy groups ( P =0.072). At 18 months, repeated revascularizations were required in 25% of patients in the 0-Gy group versus 12% of patients in the 14-Gy group ( P =0.24).

Conclusions— A single session of external beam radiation of 14 Gy of the femoropopliteal angioplasty site significantly reduces restenosis at 1 year.

Prevention of coronary artery disease in cancer patients

Improvements in cancer treatment are increasing survival rates, placing cancer survivors at increased risk of coronary artery disease (CAD). Thoracic radiation as cancer therapy can accelerate the atherosclerotic process, and some older studies suggest that mediastinal radiation can increase the CAD risk two to fivefold. The management of serum lipids using diet and drugs is the cornerstone of efforts designed to reduce CAD events. The present article reviews the association between radiation and coronary disease and provides guidelines for the prevention of atherosclerotic CAD in this patient group and in the general population of cancer survivors.

Pathology of radiation and anthracycline cardiotoxicity

Radiation-induced heart disease (RIHD) and anthracycline cardiotoxicity are two patterns of cardiac dysfunction caused by therapeutic interventions to treat malignancies. They occur in both the pediatric and adult populations and there is evidence to suggest that pediatric patients are at greater risk. This is due in part to the longer survival rates but also reflects increased susceptibility to the attendant complications caused by both therapies. Radiation can cause injury to all the components of the heart, including the vasculature, while anthracycline toxicity is generally limited to the myocardium.

Prevalence of the metabolic syndrome in relation to self-reported cancer history

PURPOSE

To estimate the prevalence of metabolic syndrome in persons with a history of cancer from a population-based sample of adults, and compare that prevalence to persons without a history of cancer.

METHODS

Data from the Third National Health and Nutrition Examination Survey were analyzed to compare prevalence and prevalence differences of the metabolic syndrome, as defined by Adult Treatment Panel III criteria, between 486 persons with a reported history of cancer and 12,526 persons with no reported history of cancer.

RESULTS

The prevalence of metabolic syndrome was 258/1000 persons for those with a cancer history and 184/1000 persons among those without, resulting in a prevalence difference of 74/1000 persons (95% CI, 38-110). Prevalence differences varied substantially by age at interview. The prevalence difference was highest among those aged 40 to 49 years (112/1000 persons) and 50 to 59 years (73/1000 persons), while those in younger (18-39 years) and older (: 60 years) age groups had a moderately higher prevalence among those without a cancer history.

CONCLUSION

These results add to the emerging concern that metabolic syndrome and associated risks for cardiovascular disease and type 2 diabetes may be an adverse late effect of cancer and/or its treatment.

Post-operative radiotherapy (PORT) or chemoradiotherapy (CPORT) following resection of stages II and IIIA non-small cell lung cancer (NSCLC) does not increase the expected risk of death from intercurrent disease (DID) in Eastern Cooperative Oncology Group (ECOG) trial E3590

To determine the influence of adjuvant therapy on the risk of DID following resection of NSCLC, we compared the actuarial rate of non-cancer related deaths of patients who had been entered in Eastern Cooperative Oncology Group E3590 (a phase III trial of adjuvant therapy in patients with completely resected stages II and IIIA NSCLC) to the actuarial death rate of age and gender matched controls. Following surgery, patients were randomized to receive either PORT (5040 cGy in 28 daily fractions) or CPORT (PORT plus four cycles of cisplatin (60 mg/m2, day 1) and etoposide (120 mg/m2, days 1-3) administered concurrently). The study accrued 488 patients, 242 to the PORT only arm and 246 to the CPORT arm. The overall 4 years actuarial rate of DID for the two arms combined, with a median follow-up of 82 months, was 12.9%, not significantly different from the 10.1% expected rate of DID, based on mortality rates for age and gender matched controls derived from US vital statistics and corrected for smoking status (p=0.16). Survival distributions with regard to DID did not differ between the two treatment arms (p=0.96). DID increased with age (treated as a continuous variable, p<0.01), but was not affected by histology, side of chest irradiated, type of surgery, FEV1 or weight loss in the previous 6 months. The risk of DID following resection of stages II and IIIA NSCLC is not increased in patients who received PORT or CPORT.

Imaging of non-small cell lung cancer

Radiologic evaluation is an important component of the clinical staging evaluation of lung cancer and can greatly influence whether the patient is treated with surgical resection, radiation therapy, chemotherapy, or a combination of these modalities. In addition to staging, the radiologic evaluation of the patient undergoing treatment and subsequent follow-up is important to the clinician for assessing treatment effects and complications. This article discusses the imaging of patients with non-small cell lung cancer and its use in management of these patients.

A comparison of Monte Carlo and Fermi-Eyges-Hogstrom estimates of heart and lung dose from breast electron boost treatment

PURPOSE

Electrons are commonly used in the treatment of breast cancer primarily to deliver a tumor bed boost. We compared the use of the Monte Carlo (MC) method and the Fermi-Eyges-Hogstrom (FEH) algorithm to calculate the dose distribution of electron treatment to normal tissues.

METHODS AND MATERIALS

Ten patients with left-sided breast cancer treated with breast-conservation therapy at the University of California, San Francisco, were included in this study. Each patient received an electron boost to the surgical bed to a dose of 1,600 cGy in 200 cGy fractions prescribed to 80% of the maximum. Doses to the left ventricle (LV) and the ipsilateral lung (IL) were calculated using the EGS4 MC system and the FEH algorithm implemented on the commercially available Pinnacle treatment planning system. An anthromorphic phantom was irradiated with radiochromic film in place to verify the accuracy of the MC system.

RESULTS

Dose distributions calculated with the MC algorithm agreed with the film measurements within 3% or 3 mm. For all patients in the study, the dose to the LV and IL was relatively low as calculated by MC. That is, the maximum dose received by up to 98% of the LV volume was < 100 cGy/day. Less than half of the IL received a dose in excess of 30 cGy/day. When compared with MC, FEH tended to show reduced penetration of the electron beam in lung, and FEH tended to overestimate the bremsstrahlung dose in regions well beyond the electron practical range. These differences were clinically likely to be of little significance, comprising differences of less than one-tenth of the LV and IL volume at doses > 30 cGy and differences in maximum dose of < 35 cGy/day to the LV and 80 cGy/day to the IL.

CONCLUSIONS

From our series, using clinical judgment to prescribe the boost to the surgical bed after breast-conserving treatment results in low doses to the underlying LV and IL. When calculated dose distributions are desired, MC is the most accurate, but FEH can still be used.